In the U.S., nearly 500,000 patients suffer an ST-elevation myocardial infarction (STEMI) each year. Most emergency departments (EDs) lack the local capabilities to perform primary percutaneous coronary intervention (PCI) for myocardial reperfusion. Thus, patients must be transferred to capable facilities, but inefficiencies in this process cause delays in timely myocardial reperfusion and worsen patient outcomes. The time to reperfusion for transferred STEMI patients greatly lags behind those patients who present directly to PCI centers and fails to meet national benchmark standards in 90% of cases. Inadequate measurement and understanding of the timing and processes of care at transferring EDs has hindered improvement in the timeliness of STEMI patient transfer. Moreover, the study of relational coordination, communication, and organizational design, collectively known as organizational behavior, is an accepted approach to study performance and variation in complex health systems. It has not yet been applied to the transfer of STEMI patients, but would likely reveal important targets for intervention. This proposal describes a career development plan that enables the candidate to gain expertise in how organizational behavior affects patient care, through the acquisition of advanced qualitative and quantitative skills for future implementation studies. The Specific Aims are: 1) Examine transferring ED data for factors associated with delays to myocardial reperfusion; 2) Conduct a detailed qualitative study of the practices that affect patient transfer for primary PCI; and 3) Examine the association between relational coordination and time spent at transferring EDs. The candidate is uniquely qualified as an emergency physician and PhD candidate in operations management. The career development plan builds on this foundation to provide: a) advanced skills in qualitative methods (e.g., patient and staff interviewing skills, and observation), biostatistics, and organizational theory; b) further development of scientific communication skills through manuscript preparation, grant writing, and conference presentations; and c) a multidisciplinary mentored research experience with international experts in transitions of care, qualitative research, process intervention development, and trial design. The institutional environment is outstanding, including a qualitative research center; nationally ranked graduate programs in the candidate's fields of study; and the national CTSA coordinating center. This career development award will allow the candidate to develop expertise in measuring the performance of healthcare systems during inter-facility patient transfer, a deep understanding of the relationship between system performance and patient outcomes, and targets for intervention to improve the timeliness of patient care for myocardial infarction. This award will position the candidate to become an R01-funded independent investigator who implements and evaluates process interventions to improve patient outcomes.